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Objectives: Colorado has the lowest rate of measles vaccination in the entire country, partially due to the ease of obtaining non-medical exemptions. Our primary objective was to determine the magnitude and cost of a measles outbreak in Denver at current vaccination coverage levels. We then simulated the effect of changing the Colorado non-medical exemption complexity to medium or difficult. MethOds: An agent based transmission model simulated the transmission of the measles virus in Denver following the introduction of a measles case. We modeled public health response, including contact tracing and quarantine of cases. Model outputs included the number of secondary cases, hospitalizations and deaths. Four vaccination scenarios were modeled: Colorado vaccination rate, national vaccination rate, Colorado vaccination rate under medium exemption regulations, and Colorado vaccination rate under difficult exemption regulations. Results: At the Colorado vaccination rate, seven secondary cases followed the introduction of an index case, two of which required hospitalization. This outbreak ranged in cost from $111,048-$338,304, which is equivalent to the purchase of 5,580-17,000 measles vaccines. This could increase 2-dose vaccination coverage in Denver by 1.3%. If Colorado increased their difficulty in obtaining non-medical exemptions, the number of secondary cases reduced by 86%, alleviating costs related to public health interventions and the negative consequences of a measles outbreak. At the national vaccination level, no other individuals became infected due to herd immunity. cOnclusiOns: Herd immunity is not established at the Colorado vaccination rate and thus an outbreak is likely following the introduction of an index case. There is an inverse relationship between non-medical exemption complexity and exemption rate. Increasing vaccination coverage by as little as 3.1% (from easy to medium complexity) would reduce the likelihood and magnitude of an outbreak. Adding a required education component or a written statement of objection would be a prudent public health nudge toward measles herd immunity.

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Background/objectives: To ascertain the effect on body weight of 14 days of bolus enteral feeding with mixed meal (MM) and electrolyte solution (ES) in ambulatory adults with type 2 diabetes and obesity, and also the safety and feasibility of using a modified, intraorally anchored enteral feeding tube for this purpose. Subjects/methods: We conducted a randomized, crossover pilot trial with 16 participants. A 140 cm, 8-French feeding tube was placed in the jejunum under electromagnetic guidance and anchored intraorally. Participants were randomized to self-administer 120 mL 523 kJ (125 kcal) MM, or 50 kJ (12 kcal) ES four times/day for 14 days. After ≥14 days without the tube, participants crossed over to the other treatment. The primary outcome compared weight change between treatments. Thereafter, participants could elect to undergo additional MM cycles. Participants were encouraged to continue with all usual activities including eating ad lib throughout the study. Results: Ten participants withdrew prior to completing two randomized 14-day cycles (4 social, 3 intolerant of anchor, and 3 intolerant of tube). Six participants were assessed for the primary outcome and showed no significant difference in weight loss between MM and ES (p = 0.082). For the secondary outcome of within-group weight loss, average weight loss from baseline was significant for MM but not for ES: −2.40 kg (95% CI: −3.78, −1.02; p = 0.008) vs. −0.64 kg (95% CI: −2.01, 0.74; p = 0.27). A total of 23 2-week cycles were completed (12 paired, 2 unpaired, and 9 additional), with no significant adverse events for 334 days of tube use. Conclusions: Repeated bolus nutrient administration via enteral feeding tube is associated with weight loss in adults with obesity and type 2 diabetes, with no significant difference seen between MM and ES feeds. The prototype device was safe, but requires development for further investigation into the effect of bolus jejunal feeding on weight and to improve acceptability.

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